It’s open enrollment time of year……

It’s that time of year again when patients begin asking which plan they should choose during their employers open enrollment period.  So we thought we would define the different flavors of dental benefit plans out there.

There are probably 50 to 100 different dental benefits providers in the Columbus Ohio area.  And within those plans there are even more different flavors of the plans that were negotiated between your employer and the Insurance company.   A Metlife plan at company A isn’t the same plan as the Metlife Plan at company B.

Dental Plans typically fall into these catagories.  If you are having difficulties figuring out your plan choices, fax us(486-2608) a copy of the pages from your benefits handbook.  

PPO Plans

• You are free to choose any dentist 
• If you choose a dentist from a list, the patient is given financial incentives.  How great are the financial incentives?  That’s hard to determine without a defined fee schedule from your plan.  In our office we’ve seen the difference in cost for a cleaning be nothing.  On average the difference is between $5 and $15 per cleaning. 
• Think about this: Does choosing a dentist on the list save me money, or my insurance company money?
• The PPO Plan pays all or part of the dentist’s fee to the extent that it does not exceed the UCR fee for that service.  How insurance companies calculate the UCR fee

DPO or DMOs

• Under these plans you must choose a dentist from a list to receive any benefit.
• If you do not choose a dentist on the list the entire cost of the dental visit will be your responsibility

My plan says I will be covered up to 80% or up to 100% so I’ve got a great plan, right?

Many plans tell their participants that they will be covered “up to 80% or up to 100%” but do not clearly specify the plan UCR fee schedule, allowance, annual maximum or limitations.  The UCR fee schedule is what they will pay 80% of, not the fee your dentist charges.  (See post on how insurance companies calculate the UCR fee) 

By the way, your dental office has no idea what the UCR fee schedule is for your particular plan with your insurance company.   We don’t know for certain what your insurance company will pay until we receive the claim back.  Based on our experience, it is realistic to expect dental insurance to cover about 50% for major restorative services like crowns, large fillings, and root canals. 

The good news is that most dental benefit plans pay the majority of the fee for your dental maintenance such as cleanings and xrays.  And coming in for professional dental cleanings on a regular basis can help us keep small problems from becoming major restorative stuff.

So which should you cho0se if you are a Grandview Dental Care Patient? 

You need to decide what dental plan to choose based on your needs.  If you choose a plan where you are allowed to choose any dentist(typically a PPO) you will receive dental benefits to help you pay for the cost of the dental work you have done.

Cigna, Metlife, Anthem, UHC, etc, as long as you can choose any dentist, you will have a certain level of coverage from the insurance company and a certain level of out-of-pocket depending on your plans fee schedule.  Remember, you get what you pay for.  If you pay $10 per month for dental coverage for your entire family, you are going to have some out-of-pocket expense for your dental care.

What does UCR fee stand for?

Well… the letters in UCR stand for Usual, Customary, and Reasonable.  Almost sounds like the Insurance company is doing extensive surveys of dental fees in your zip code and then taking the average, say 70% - 75%,  fee.  But guess what, that is not what the Insurance company does.

Insurance companies  calculate the UCR in differing ways, but it’s usually between the 50th and 80th percentile of what fees are in a geographical area.  The geographical area is not limited to a certain radius around a certain zip code.  It can include an entire state and includes all the rural, urban, and suburban dentists and we all know that location can effect the price for good and services. 

The UCR fee guide generated by the insurance company is a price they will allow for every dental procedure they cover.  This is not based on what a dentist actually charges, but what the dental insurance wishes to cover for the premium your employer wants to pay. 

And to further complicate things the Insurance company typically only covers 80% of their UCR fee, so dental benefits were meant to have some patient out-of-pocket expense. 

It’s amazing that the UCR fee varies between insurance companies and even between different plans in the same company. 

This is because dental benefits and the associated UCR fee schedule are determine by the negotiations between the insurance company and your employer.  And the better the dental benefits the plan offers the more you and your employer pay in the premiums to the insurance company.  Your employer has likely selected a UCR fee schedule that corresponds to the premium cost they desire.

So the adage… you get what you pay for…. is alive and well with dental insurance.  

So if my out of pocket is less if I go to a dentist on a list, why wouldn’t I just go to a dentist on a list to save money.

Whew that was a long headline!  Do you make all of your buying decisions based on cost?  Do you buy the cheapest car?  The cheapest television?  Go to the least expensive place to eat every time you go out? 

A dentist on an insurance list has agreed to cut their fees in order to get on the list.  They typically get on the list because they need new patients.  Ask yourself, why do they need new patients?  We get 85% of our new patients based on referrals from existing patients.  Current patients send their friends and family to us because they trust us and appreciate what we do for them.  This is a big compliment to us!

When a dentist is on a list what expenses are they cutting to keep their bottom line the same?

A dentist sets their fees in order to meet their business expenses, office building, employee costs, lab costs, dental supply costs, electric, continuing education, better equipment etc.  If a dentist has to cut their fees to be on a list how do they make up those costs? 

Think about it.  A dentist is not going to participate on a list in order to take home less so they need to cut costs somewhere…. but where are they cutting costs and are you ok with going to dentist that cuts costs in these areas?

Instead they are cutting costs in other areas that can effect your experience as a patient and even the quality of the work done in your mouth.  

• Because they need to see more patients, the doctor can not take the time off to take continuing education classes that help them get better at what they do or learn a new technique which makes things more comfortable for you the patient. 
• They may use inferior dental materials that are cheaper and don’t last as long.
• They may use a lower quality dental lab because the cost is lower. 
• They may not pay their employees very well so they don’t attract and keep the best employees.  It’s comforting to see the same hygienist at each cleaning or talk to the same dental assistant that asks about your kids and knows you like nitrous oxide or have a latex allergy and to be greeted when you walk in the front door by someone you know.  
• Many times it effects your wallet because they overbook their schedule because they have to see more patients which means you are stuck waiting in the waiting room.  Time is money ya know.
• Or perhaps you are rushed through your appointment because patients are backed up in the waiting room.

So, the money question.  Does choosing a dentist on a list save me money or my insurance company money?

Consider this:  In 2007 we were a participating provider with a big name insurance company that happens to use a cartoon character in a lot of their advertising. 

• We had patients that participated in this plan and came to see us “out-of-network” prior to 2007. 
• Prior to 2007 some of these patients that came to see us “out-of-network” their out-of-pocket on their cleaning was 50¢. 
• The insurance company paid our fee for a cleaning except for 50¢
• When these same patients came in for their cleaning in 2007 our fee for a cleaning hadn’t changed.
• Because we were a provider on the list and had contracted to take reduced fees, the insurance company only paid 66% of our fee for a cleaning which saved the insurance company over $22.
• So the insurance company saved $22, the patient saved 50¢!
• No wonder the insurance company wants you to go to a provider on their list.  It’s better for them but is it better for you?  Only you can decide that.

By the way, We got off the list in late 2007 because we were unwilling to shortcut the way we treat and care for our patients.

I guess that depends on your definition of insurance but when you compare dental insurance to the other insurances that you carry on your home, car, life, and medical it seems like more of a dental maintenance plan rather than insurance.

Dental Insurance … it’s not really insurance at all

Insurance is defined as a third party taking the risk of a catastrophic loss.  The annual limit of most dental plans is a maximum reimbursement of $1200. 

Now, you may not have $1200 in your wallet and it is a lot of money, but there is nothing catastrophic about $1200.  It lacks the catastrophe that insurance was designed to protect us against.  If you lost your home to a fire, totaled your car, or had a major medical surgery that required a long hospital stay, that would be catastrophic.

If your other insurances worked this way, there would be rebellion!

Say for example that you totaled your new car the insurance man offered $1,200 total settlement.   You would call the state insurance agency, your lawyer, the Better Business Bureau, 6 on Your Side and complain.  We have expectations of coverage for losses that would be significantly unmet.  However, this is exactly how most dental “insurance” works.

So, lets call dental coverage what it really is… a maintenance plan

If your car insurance only covered oil changes twice per year, annual tire rotation and wiper blades, and a tune-up every three years, it would be useful to have, but you wouldn’t consider it insurance. 

A dental benefits plan helps us keep our mouths in good health but if something major should happen that requires a crown, root canal, dental implant, etc, our dental “insurance” isn’t going to cover the entire cost.  And if we have hit our annual maximum, it will be all out of pocket.

The $1200 annual maximum hasn’t kept up with inflation

When dental insurance was first introduced in the late 60s the annual maximum was about $1000.  If you use a 3% inflation rate, dental insurance today should cover over $5000 per year. 

Is a dental benefits plan useful to have?

Absolutely!  If you keep in mind that it is designed for the maintenance of your teeth not to cover everything. 

Most dental benefit plans cover the majority of the fees for cleanings, x rays, and doctor exam.  These procedures are essential to maintaining your teeth.  When problems do arise, your dental benefits will go a lot farther if you catch the decay when it is small and easy to fix with a small filling. 

Decay left untreated doesn’t disappear.  It just gets bigger and costs more to fix and you will have more out of pocket costs to cover.

Yes, You can use your Health Savings Account for your preventive and restorative dental expenses.

We recommend that you speak to your Health Savings Account representative for all the details but based on our research a Health Savings Account can be used on all non-cosmetic dental expenses, including Invisalign Orthodontics.

What is a Health Savings Account?

A Health Savings Account(HSA) is an alternative to traditional health insurance.  HSAs enable you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis.  Please see the US Treasury’s website for all the details on Health Savings Accounts.  Another useful article on HSAs from Kiplinger.com

For the purpose of this blog post here is a summary of my findings on HSAs.

• Must be used in conjunction with a High Deductible Health Plan (HDHP)
• You own and control the money in the HSA
• The money in the HSA rolls over from year to year until it’s gone
• You can sign up for an HSA through your employer, banks, and insurance companies
• Your contributions to your HSA can be deductible when you file your taxes
• You can use the money in the HSA for qualified medical and dental expenses including orthodontics.  For a partial listing on what is a qualified expense see the following IRS document

It’s a contract between your Employer and the Insurance Company

Your dental insurance is based upon a contract made between your employer and an insurance company. This contract determines:

• What your employer pays for the dental benefit which in turn effects what you pay
• What sort of dental procedures your plan will cover.  Many plans don’t cover procedures that have been the standard of care for over a decade.  (tooth colored fillings, dental implants, etc)
• The fee schedule or how much money will be paid for particular procedures and how much you the patient will have to pay
• How much coverage you have each year in dental benefits
• Whether or not you can choose any dentist or have to pick a dentist from a list

We don’t have the insurance company magic phone number

Believe it or not we don’t have a magic phone number or a designated contact at the insurance company.  We submit claims to 100s of different insurance companies.  Multiply that by the number of employers with different flavors of policies with those same insurance companies and it becomes challenging to get the definitive answers to our patients questions.  

We will make reasonable attempts to contact the insurance company to get things resolved but patients must play a role also to be successful. 

We don’t know exactly what your insurance company will pay until we receive the claim back

We will always be able to tell you what our fee is for a particular dental procedure and we can usually estimate what your insurance will pay.  But until we get the claim back we don’t know for sure what your insurance company will pay. 

We understand that this makes it very difficult for you to budget on bigger procedures and offer a variety of payment options so that you can get the dental care you need.

Dental insurance benefits are different than health insurance

Dental insurance benefits differ greatly from general health insurance benefits, in both coverage and price.  Do you know what you pay for your dental insurance?   Check your pay stub and compare it to the cost of your medical coverage.  Big, difference, eh?

Knowing that dental insurance isn’t really insurance (coverage for a chatostophic loss) it’s more of resource for payment.  Know that the big stuff is still going to have some out of pocket cost and that there is a maximum you can use each year. 

But also realize that the big stuff doesn’t happen year after year.  You may have a year with a root canal and a crown(big stuff) but then have “ok” check-up appointments for the next 5.  And remember, that small filling the dentist found today will eventually turn into something bigger and more expensive if you don’t get it taken care of.  The decay doesn’t go away…. it just gets bigger.

Dental Benefits have not ever increased  

In 1971, your dental insurance benefits were approximately $1000 per year. Some 35 years later, you will note that your benefits are still approximately $1000 per year. Figuring a 6% rate of inflation per year, you should be receiving over $5000 per year in dental benefits. Your premiums have increased, but your benefits have not. Therefore, dental insurance is never a pay-all; it is only an aid.